Medicare Eligibility and Racial and Ethnic Disparities in Operative Fixation for Distal Radius Fracture

This cohort study investigates whether age-related Medicare eligibility is associated with racial and ethnic disparities in the decision to use surgical management for distal radius fracture.


eAppendix. Results of Sensitivity Analysis
The results of our fuzzy regression discontinuity analysis are presented in eTable 4. In this analysis, the expected mean use of ORIF at age 65 is less for all racial and ethnic groups, particularly Black patients, as compared to the main analysis.Thus, there is greater expected White-Black and White-Hispanic disparity than reported in the main analysis.In this analysis, there was a significant, though subtle, decline in ORIF use in White patients immediately at 65 years.In this model, White patients receiving ORIF declined 2.9 percentage points (from 36.4% to 33.5%; 95% CI=-5.3,-0.5).Conversely, in the main analysis, there was a positive adjusted discontinuity in ORIF use at age 65 in White patients, although this was not statistically significant.In both models, there was a predicted decline in ORIF use at age 65 in minoritized patients, yet none of these findings achieved statistical significance.In this model, there was no significant difference in the White-minoritized group disparity in the presence of Medicare eligibility.The results of our regression discontinuity analysis excluding patients with Medicare Advantage are presented in eTable 5.The expected means and disparities at age 65 years in the absence of Medicare are the same as those observed in the main analysis.As compared to the main analysis, the adjusted discontinuity in White-Black disparity is of lesser magnitude and does not meet statistical significance (p=0.09).c Column presents the expected disparity at age 65 years, which is based on the local linear association between age and outcome (use of ORIF vs. all other treatments).The expected disparity subtracts the expected mean for minoritized groups from the expected mean for White populations at age 65 years.
the lower end of radius S52.501 A,D,G,K,P,S Unspecified fracture of the lower end of right radius S52.502 A,D,G,K,P,S Unspecified fracture of the lower end of left radius S52.509 A,D,G,K,P,S Unspecified fracture of the lower end of unspecified radius S52.52 Torus fracture of lower end of radius S52.522 A,D,G,K,P,S Torus fracture of lower end of left radius S52.529 A,D,G,K,P,S Torus fracture of lower end of unspecified radius S52.53 Colles' fracture S52.531 A,D,G,K,P,S Colles' fracture of right radius S52.532 A,D,G,K,P,S Colles' fracture of left radius S52.539 A,D,G,K,P,S Colles' fracture of unspecified radius S52.54 Smith's fracture S52.541 A,D,G,K,P,S Smith's fracture of right radius S52.542 A,D,G,K,P,S Smith's fracture of left radius S52.549 A,D,G,K,P,S Smith's fracture of unspecified radius S52.55Other extraarticular fracture of lower end of radius S52.551 A,D,G,K,P,S Other extraarticular fracture of lower end of right radius S52.552 A,D,G,K,P,S Other extraarticular fracture of lower end of left radius S52.559 A,D,G,K,P,S Other extraarticular fracture of lower end of unspecified radius S52.56 Barton's fracture S52.561 A,D,G,K,P,S Barton's fracture of right radius S52.562 A,D,G,K,P,S Barton's fracture of left radius S52.569 A,D,G,K,P,S Barton's fracture of unspecified radius S52.57S52.571 A,D,G,K,P,S Other intraarticular fracture of lower end of right radius S52.572 A,D,G,K,P,S Other intraarticular fracture of lower end of left radius S52.579 A,D,G,K,P,S Other intraarticular fracture of lower end of unspecified radius S52.59Other fractures of lower end of radius S52.591 A,D,G,K,P,S Other fractures of lower end of right radius S52.592 A,D,G,K,P,S Other fractures of lower end of left radius S52.599 A,D,G,K,P,S Other fractures of lower end of unspecified radius

eTable 3 .
CPT and ICD-10 Procedure Codes for Management of Distal Radius Fracture OPEN REDUCTION AND INTERNAL FIXATION (ORIF) 25607 Open treatment of extraarticular distal radius fracture with or without internal or external fixation 25608 Open treatment of extraarticular distal radius fracture with internal fixation of two fragments 25609 Open treatment of extraarticular distal radius fracture with internal fixation of three or more fragments 25620 Open treatment of distal radius fracture 0PSH04Z Reposition right radius with internal fixation device, open approach 0PSH06Z Reposition right radius with intramedullary internal fixation device, open approach 0PSJ04Z Reposition left radius with internal fixation device, open approach 0PSJ06Z Reposition left radius with intramedullary internal fixation device, open approach 0PSK04Z Reposition right ulna with internal fixation device, open approach 0PSL04Z Reposition left ulna with internal fixation device, open approach 0PSK06Z Reposition right ulna with intramedullary internal fixation device, open approach 0PSL06Z Reposition left ulna with intramedullary internal fixation device, open approach PERCUTANEOUS PINNING / FIXATION 25611 Percutaneous skeletal fixation of distal radius fracture 25606 Percutaneous fixation distal radius fracture or epiphyseal separation 0PSH34Z Reposition right radius with internal fixation device, percutaneous approach 0PSJ34Z Reposition left radius with internal fixation device, percutaneous approach 0PSH36Z Reposition right radius with intramedullary internal fixation device, percutaneous approach 0PSJ36Z Reposition left radius with intramedullary internal fixation device, percutaneous approach 0PSK34Z Reposition right ulna with internal fixation device, percutaneous approach 0PSL34Z Reposition left ulna with internal fixation device, percutaneous approach 0PSK36Z Reposition right ulna with intramedullary internal fixation device, percutaneous approach 0PSL36Z Reposition left ulna with intramedullary internal fixation device, percutaneous approach OTHER SURGICAL TREATMENT: EXTERNAL FIXATION 20690 Application of a uniplane unilateral external fixation system 20692 Application of a multiplane unilateral external fixation system 0PHH35Z Insertion of external fixation device into right radius, percutaneous approach 0PHH3CZ Insertion of ring external fixation device into right radius, percutaneous approach 0PHH3BZ Insertion of monoplanar external fixation device into right radius, percutaneous approach 0PHH3DZ Insertion of hybrid external fixation device into right radius, percutaneous approach 0PHJ35Z Insertion of external fixation device into left radius, percutaneous approach 0PHJ3CZ Insertion of ring external fixation device into left radius, percutaneous approach 0PHJ3BZ Insertion of monoplanar external fixation device into left radius, percutaneous approach 0PHJ3DZ Insertion of hybrid external fixation device into left radius, percutaneous approach 0PHK35Z Insertion of external fixation device into right ulna, percutaneous approach 0PHK3CZ Insertion of ring external fixation device into right ulna, percutaneous approach 0PHK3BZ Insertion of monoplanar external fixation device into right ulna, percutaneous approach 0PHK3DZ Insertion of hybrid external fixation device into right ulna, percutaneous approach 0PHL35Z Insertion of external fixation device into left ulna, percutaneous approach 0PHL3CZ Insertion of ring external fixation device into left ulna, percutaneous approach 0PHL3BZ Insertion of monoplanar external fixation device into left ulna, percutaneous approach 0PHL3DZ Insertion of hybrid external fixation device into left ulna, percutaneous approach CLOSED TREATMENT 25600 Closed treatment of distal radius fracture, without manipulation 25605 Closed treatment of distal radius fracture, with manipulation 29065 Application of long arm (shoulder to hand) radius, external approach 0PSJXZZ Reposition left radius, external approach 0PSKXZZ Reposition right ulna, external approach 0PSLXZZ Reposition left ulna, external approach 2W3CX1Z Immobilization of right lower arm using splint 2W3CX2Z Immobilization of right lower arm using cast 2W3CX3Z Immobilization of right lower arm using brace 2W3CXYZ Immobilization of right lower arm using other device 2W3DX1Z Immobilization of left lower arm using splint 2W3DX2Z Immobilization of left lower arm using cast 2W3DX3Z Immobilization of left lower arm using brace 2W3DX4Z Immobilization of left lower arm using other device © 2023 Benitez TM et al.JAMA Network Open

eTable 4. Medicare Eligibility Age-Related Discontinuities in Racial and Ethnic Disparities in DRF Management (Sensitivity Analysis: Fuzzy Regression Discontinuity Design)
Column presents the expected mean at age 65 years, which is based on local linear association between the age and outcome (use of ORIF vs. all other treatments).The expected mean contain the counterfactual outcome at age 65 years in the absence of treatment (e.g., the expected outcome at age 65 years without Medicare).Column presents the expected disparity at age 65 years, which is based on the local linear association between age and outcome (use of ORIF vs. all other treatments).The expected disparity subtracts the expected mean for minoritized groups from the expected mean for White populations at age 65 years.© 2023 Benitez TM et al.JAMA Network Open a b Adjusted discontinuity estimates are in percentage points.c

eTable 5. Medicare Eligibility Age-Related Discontinuities in Racial and Ethnic Disparities in DRF Management (Sensitivity Analysis: Excluding Medicare Advantage)
Column presents the expected mean at age 65 years, which is based on local linear association between the age and outcome (use of ORIF vs. all other treatments).The expected mean contain the counterfactual outcome at age 65 years in the absence of treatment (e.g., the expected outcome at age 65 years without Medicare).
a b Adjusted discontinuity estimates are in percentage points.